What To Expect From An ADHD Evaluation
by Debra Lombardo, LPN
“Help! My child is having trouble in school. He is always out of his seat, gazing out the window and not completing his assignments. Homework is a nightmare and he is losing the few friends he has.”
Does this sound familiar? It certainly does to me, Debra Lombardo LPN, Clinical Coordinator at Pediatric Associates of Connecticut. I have worked at Pediatric associates for over 15 years. Of our 20,000 active patients, over 600 have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).
Among my other duties, I am responsible for coordinating all the ADHD patients of Neil Vitale, MD. As many of you know, Dr. Vitale has a special interest in behavior issues and is responsible for evaluating, diagnosing and treating most of our ADHD patients.
The process of evaluating children with ADHD starts when parents call with concerns about their child. I speak with these parents, gather all the appropriate information and perform a “Behavioral Triage”. Depending on the issues involved I next mail out parent and teacher questionnaires. These questionnaires will help us to gain an understanding of the behavior and performance of your child at their two most common settings-home and school/day care. After the questionnaires are completed and returned, along with any other recent school or psychological evaluations, Dr. Vitale reads through this information to see if an evaluation is appropriate with him or a different specialist, such as neurologist or psychiatrist.
Evaluations are done on Wednesday mornings at Pediatric Associates. Child and one or both parents, and a sitter for younger children, are required to be there. After a brief physical and neurologic examination, the younger children go with the sitter, while Dr. Vitale spends about 90 minutes with the family and gathers information about the child’s present difficulties, social and family history, and reviews previous school testing (if any has been completed), and the questionnaires. Older teens are welcome to join us for this part of the evaluation. A diagnosis is then made and treatment options (educational, behavioral, and pharmacological) are discussed with parents. Dr. Vitale takes the time to make sure parents fully understand, and feel comfortable with the place medication has in the treatment of ADHD. He then outlines the steps involved in both working with school personnel to create an Individualized Education Plan (IEP) and starting their children on medication if appropriate.
If parents feel medication is appropriate for their child, a 2-4 week medication trial is carried out. When parents opt to try medication for their children, they are often quite eager and want to get started quickly. Dr. Vitale reinforces the concept of a slower process that may take several weeks and several medications to find the best medication for your child. A typical medication trial would be to have the first week as baseline (no medication), the second week would be the initial dose of medication and 3rd week would be a higher dose of same medication. Brief ADHD rating scales are given to each teacher to be filled out on a daily basis during this trial period. Due to recent recommendations, an EKG will be ordered before the medication trial starts. At the end of the three weeks the parents return the forms to our office. We tally the scores and read any and all comments made by the teachers. I then call the parents to discuss with them their views on how the child tolerated the medication, and if there were any side effects. The decision is then made on how well the medication worked. If the medication had a positive effect on the child’s behavior and performance with few, if any, side effects, a prescription is dispensed for the initial 30 days.
To facilitate requests for ADHD medication refills I have a dedicated voice mailbox that can be accessed 24 hours a day. Parents leave all pertinent information ( name, date of birth, address, phone number, name of medication and whether they will be picking it up or want it mailed) on this voice mailbox which is checked every weekday. Prescriptions are then written the next day. Since our parents know that it could take a few days to get their prescription written, it encourages them to plan ahead so they do not run out and need medication emergently. I update the medication log in each patients chart when medication and refills are dispensed.
We require that children who are taking medication for ADHD be seen at least twice a year. This allows our providers to check blood pressure, heart rate, growth and assess the effectiveness of the medication and monitor for side effects. When I book this type of appointment in the computer a special code is used allowing Dr. Vitale twice as much time as a regular physical. Dr. Vitale and I have developed a special form to be used at these ADHD follow-up appointments. It is different in that it is blue rather than white and set up in such a way that pertinent information such as medication, side effects and school services is recorded in a systematic way. The charts themselves are also different. They are divided to allow us to keep the ADHD information separate from the rest of the chart.
Many times the initial call from a parent is quite frantic. If I am not able to return their call within an hour they often call back again and again becoming more frustrated with each call. One of the best bits of wisdom that Dr. Vitale has shared with me is “behavior issues are rarely true emergencies “. I make every effort to talk with parents on a timely basis, but often they feel it is not fast enough. We try to instill in parents the concept of ADHD as a life-long chronic condition. Parents are made to understand that their children did not develop this condition yesterday and while it is important to provide timely evaluation and treatment, it will not be on an emergency basis.
Due to our mutual interest in ADHD, Dr. Vitale and I have conducted two recent studies. The first was “The Impact of Clinical Practice Guidelines on the Identification of Co-morbidity in Children with ADHD in a Primary Care Setting.” We found that by using the recently published clinical practice guidelines for diagnosing ADHD the number of childrenwe identified with an additional psychiatric condition was increased significantly beyond historic levels. We hope this will encourage primary care providers to do a more complete initial evaluation of children with ADHD, thus allowing providers to develop more appropriate therapeutic interventions for these children. The second study was “The Comparison of Medication Usage and School Services in Combined and Inattentive Subtypes of ADHD.” We wanted to compare children with combined and inattentive subtypes of ADHD in a primary care setting with regard to medication treatment and school-based services. We thought these two groups would differ significantly but we found there were many more similarities than differences. Dr. Vitale and I presented these studies at the national CHADD (Children and Adults with Attention Deficit Hyperactivity Disorder) conference held in October of 2003 in Denver, Colorado.
I hope this gives you an idea of the interest and effort that goes in to your ADHD evaluation. We at Pediatric Associates, with Dr. Vitales guidance, have ensured that children with ADHD are diagnosed and traeted unlike anywhere else.